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f—�.-- <br /> SAN., JOAMIN Environmental Health Departure°it <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> ..,erected wlthl 0 a s of <br /> Any INQR violations noted in the"Notice to Comply"in the attached Inspection Report must be Department(EHD) address at <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health <br /> the bottom of this form within 30 days of receipt of the Inspection Report. NSC 25404.1_2(c)(1) <br /> All corrections to other vialations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD wit i d unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the abase noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample resultslmanifestsltraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: S 2 Inspected By: Z <br /> Z` <br /> Facility Address: `j CERS ID: �O ` <br /> I certify under penalty of law that. <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> X Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. l am aware that there are significant penalties for submitting false information, including the possibility of a fine andlc <br /> imprisonment for nown violations. (HSC 25191) <br /> G <br /> Name: Title: d�1J ti <br /> Signature: Date: <br />